P - 83347RE(1UEST FOR ELECTRICAL INSPECTION
6,.��J = 0 7 9� Minnesota State Board of Electricity
.; 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 "�'
Home Dualex Apt. Bldq. Other: New Ad
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in this space and on
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ack of the white copy
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Calculaie lnspeciion fee - This lnspection Requesi will not be accepted without the correct fee:
Other Fee # Service Entranc ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall / 0 to 0 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sian/Oudine Lta. Xfmr. ����C
Alarm/Remote
Swimminq Pool
Ihaf I
m described herein on the dates stated
Dafe
Find . I U°�e'l'�� .� a-1
Investigative Fee /�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation dafe printed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rou h-in ins o� r uired? ❑ Yes
g pecli eq ❑ No Inspection Ofher Than RougMn: ❑ Ready Now ill Call
,��, `� 1_� $ (You must call the inspeclw when ready) Date Ready:
I, �licensed confractor ❑ owner hereby request inspection of the above elechical work at:
lob Address (Sheet, Box, or Route No.) Ciy Zip Code
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Section No. Township Name or No. Range No. Fire No. Couny
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nf Phone No.
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Power Supplier Address
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Eleclrical Conkacfor �Company Name) Conhaclor License No. Masi
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Mailing Address (C cror or Owner Performing Insfallation)
Auf orized Sign ture �Confracfor or Owner Pe ming Installafion� � _� Phor
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IB-0OOOIA- 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY